Social science 

The right to the truth about the latest diagnosis. Last right last sickness

Psychology of terminal patients The concept of E. Kübler-Ross “death as a “growth stage”” The right to the truth about the last diagnosis Palliative medicine CHIBULAEVA V. V. 240 GR

What does the psychology of terminal patients testify to? This block of arguments against euthanasia is based on the data of psychology, highlighting the following theses: a terminal illness may have a higher meaning for the patient; a request for euthanasia may be a request for help; there is a danger of inducing the doctor by the patient; euthanasia, which is by no means easy for a doctor, is an irreparable mistake there are limits to the responsibility of medical personnel legalization of euthanasia will undermine confidence in the doctor's work

Terminal illness: new facets of being the main problem suffering person - to see the meaning of torment. If this meaning exists, a person will endure any pain. If not, even a runny nose can be a reason for suicide. The very absence of this meaning can be more torment than illness. If a person does not see the meaning of his cross, he is not able to discern this meaning in the suffering of others, and therefore cannot help them. This question has always stood before the human mind, but it is becoming especially acute today, in the era of total hedonism.

Questions that are posed in communication with terminal patients: Why are these last days? Is it permissible to hide the truth about the true diagnosis from a terminal patient until the last hour? What is the difference between medical work with the dying and medical care for the convalescent?

The answers to these questions were given by the famous scientist Elisabeth Kübler-Ross, whose research was devoted to the psychology of terminal patients. Based on a large number of observations, she identifies five stages that the psyche of a person diagnosed with a fatal illness goes through. The first stage is the stage of denial. Having learned about his diagnosis and prognosis, the person says "no, it's not me." The next stage is a protest: “why me? » The third stage is a request for a delay: "not yet". The fourth is depression: "yes, I'm dying". The fifth stage, surprising as it may seem, is the stage of acceptance: "let it be".

Why does the transition from depression to acceptance occur? One of the reasons for this is in the initial life attitude. Most often, a person lives by projecting himself into the future, by the prospect of a certain expansion, expanding his presence in this world. He plans to continue his career, buy an apartment, build a dacha, raise children, see grandchildren, etc. This is the point of application of his energy, all his vitality. The news of a fatal illness deprives a person of this future. And it turns out that he still has some strength, as long as he lived to see the diagnosis, but there is nowhere to spend it. In place of the future is emptiness, a vacuum of meaning. Further movement is impossible. The impending death really pulls a person out of the whirlwind of fuss. A person begins to notice something that he did not pay attention to before, or maybe he deliberately ignored, pushed to the periphery of consciousness. What is it about? First of all, about interpersonal relationships. Making a career, we betray, sell, forget someone. We do not visit our parents, we do not take care of our relatives, we compromise moral principles, etc. In other words, we stop seeing people as people. And then the wife becomes a washing machine and an incubator in combination. Children turn into an attribute of a prosperous family. And the surrounding humanoids become objects of manipulation, steps, a means to achieve any goals. When a deadly disease rips off this husk of internal substitutions from a person, he begins to see himself in a real light.

Fatal disease exposes all lies human life. And then a person finds a place for applying his spiritual forces (thoughts about what he needs to do). The second very important point: a person begins to see his life as a whole, maybe to consider it better, to understand why he lived, what he did in this world. This allows him to take stock and put the finishing touches. Third: approaching the border of life and death, a person can still have time to build his relationship with Eternity. Where are you going after death? Does death end the personal forever? Death is the time when a person can still raise his eyes to Heaven. In the post-perestroika years, for many terminally ill patients in Russia, the opportunity to be baptized in a hospital, bring confession, take unction, and take communion was of great importance. This right of the patient to spiritual nourishment is enshrined in Russian legislation. Thus, the time of dying does not impoverish, but, on the contrary, enriches a person, opens up new facets of being for him, fills his life with the highest meaning. This explains why, according to the research of Elisabeth Kübler-Ross, many terminally ill patients perceived near-death as the best stage of their life, as a novelty of existence. The prospect of the end gives a person the opportunity to carry out an internal revolution, to move from a hedonistic worldview to a soteriological one, and to comprehend the meaning of suffering.

What does the patient ask for when he asks: "Kill me!" ? The argument of the opponents of euthanasia is an analysis of the possible motivation for the patient's request for death. As noted by V. A. Millionshchinova, who has many years of experience with terminal patients, when a patient says “Kill me!” , he asks "Help me!" . He tries to shout to the surrounding people, to break through the bark of indifference and lies, but often his cry for help remains unanswered. The reason for the patient's mental discomfort is falsehood on the lips of doctors and visitors. He is constantly encouraged, and he feels that the ground beneath him is subsiding, but he cannot talk to anyone about this most important experience for him. In this situation, the patient needs to provide psychotherapeutic assistance. The law prohibits hiding the truth from a patient who wants to know his diagnosis. The high cultural tradition of Europe and Russia gives us the opportunity to find the right words so that a sick person does not feel misunderstood and alone.

"The patient's depressive self-esteem can induce the doctor into a hopelessness of a cure." This argument against euthanasia is given by a well-known psychiatrist, a leading specialist at the Serbsky Institute, Professor VF Kondratyev. He writes: “Patients in critical conditions may develop somatogenic and psychogenic depressions. Any depression is expressed in a subjectively nihilistic prognosis, in disbelief in a favorable outcome, and already, in its essence, can initiate the patient's requests for his speedy deliverance from suffering by mortification. Such an assessment of the hopelessness of their condition by patients who are depressed, and in fact by no means always corresponding to the real prognosis, can have two negative consequences: depression itself worsens the patient's physical condition and, secondly, the patient's depressive self-esteem can induce the doctor into hopelessness of a cure. At the same time, these depressions are reversible and, accordingly, the patient's personal attitude to the question of the struggle to save his life may change. Psychotherapy, psychopharmacotherapy, stopping depression, gives a real chance for the patient to refuse his requests for euthanasia. the psychological state of a person approaching the brink of life has not been studied so much that there is really no way to predict that at the last moment, already in the beginning of the euthanasia procedure, he will not give up his desire to die, and that he will not want to extend his life even in suffering.

The desire to "relieve the suffering" of the patient may be a hidden manifestation of selfishness on the part of others. This argument of the opponents of euthanasia is based on an analysis of the possible motivation of its supporters. Do not the words about the need to hasten the death of a seriously ill person out of compassion and mercy for him cover up an egoistic unwillingness to be with him, to share him? heartache, spend your time and energy on his support? Alas, often people do not realize what is actually hidden behind their humanism.

Is "easy death" easy? (virtual worlds and reality) The problem is that the image of euthanasia in the mass consciousness is the picture that is drawn by means mass media. However, when in contact with reality, virtual sketches can turn into a disaster. Although in many television programs the theme of euthanasia is a screen of light, into which the silhouette of the dying person is immersed, in fact the reality of suicide is not so cloudless. At best, in a person who has received a lethal dose of the drug, the instinct of life wakes up. He understands the futility of his attempts to reach out to others and stops playing this game with them. He just wants to live. But he understands that the effect of the drug is irreversible. Thus, a person dies in agony: he wants to live, but he dies, and he himself is the cause of his death. In the worst case, depression completely consumes the will to live. Then the person dies in a state of extreme despair. Even if we assume that death ends the personal existence of a person, then even then such an end to life cannot be called easy. If death is a stage of life, and consciousness is preserved after the death of the body, then eternal loneliness remains behind this line in the soul of such a person. Such a transition to such an eternity is by no means an “easy death”, rather, on the contrary, a person leaves this world with a grimace of horror and disgust. That is why, according to the Christian faith, suicide separates a person from God, dooming him to eternal torment. In any case, euthanasia is not an easy death. Will a person die in a state of mental struggle, which still gives him some hope for a posthumous justification, or will he die in a state of deep depression, such an end

Why should doctors suffer? (irreparable error) This argument of the opponents of euthanasia analyzes the situation in which the doctor may find himself after the production of euthanasia. As the works of existentialist philosophers of the 20th century show, being has a kind of moral infallibility. No matter how man distorts his nature, he will never be able to dodge himself. In this sense, it is useless to shift one's moral responsibility to the surrounding conditions. At least at some moments of his life, a person realizes that writing off any meanness to the “current situation” will not bring peace. He has no right to refer to "circumstances" because, in the final analysis, that inner yes, without which there is no action, was decisive. For the medical community, the problem of euthanasia is the problem of the consequences of an immoral act for the one who committed it. This is the act in which all humanistic and utilitarian hypotheses and utopias come into contact with the reality of the moral existence of man. And this meeting can turn into a life tragedy for the doctor. Some things are irreversible. By transgressing the commandment "Thou shalt not kill", the doctor does not simply renounce his vocation. He ceases to be human in some way. Therefore, when society speaks out against euthanasia, it also cares about doctors.

Limits of Responsibility of the Medical Community This argument upholds the moral dignity of the physician. Even if we assume that the patient is resolutely and irrevocably determined to end his life by suicide and demands to “serve” him, this does not mean that the doctor is obliged to fulfill this desire. There are limits to the doctor's responsibility to the patient. If a drug addict patient asks a doctor to provide him with morphine, the doctor has no right to satisfy this desire, although he must help him get rid of drug addiction. If the addict refuses treatment and begins to blackmail the doctor with suicide, the doctor still should not go towards his aspirations. Man is free in his decisions. The doctor must be able to refuse the patient those desires that are contrary to legislative and moral standards.

Legalization of euthanasia will undermine the trust in the work of a doctor Legalization of euthanasia will lead to the fact that patients will doubt the objectivity of the diagnosis, because the doctor's decision may hide mercenary or criminal motives. This will undermine the credibility of the medical community as a whole.

Palliative medicine is a field of health care designed to improve the quality of life of patients with various nosological forms of chronic diseases, mainly in the terminal stage of development in a situation where the possibilities of specialized treatment are limited or exhausted.

According to the definition, palliative care: affirms life and considers death as a normal natural process; has no intention of extending or shortening the life span; tries as long as possible to provide the patient with an active lifestyle; offers help to the patient's family during his severe illness and psychological support during the period of bereavement; uses an interprofessional approach to meet all the needs of the patient and his family, including the organization of funeral services, if required; improves the patient's quality of life and can also positively influence the course of the disease; with a sufficiently timely implementation of measures in conjunction with other methods of treatment, it can prolong the life of the patient.

The concept of "palliative care" arose in connection with the treatment of cancer patients and has traditionally been focused on the needs of the dying and their loved ones. It now applies to all types of palliative care, regardless of the nature of the patient's illness. The WHO Declaration (1990) and the Barcelona Declaration (1996) call on all states of the world to include palliative care for patients in their national health systems. The main principle of palliative care is that no matter what disease the patient suffers from, no matter how severe this disease is, no matter what means are used to treat it, you can always find a way to improve the patient's quality of life in the remaining days.

Palliative care: relieves pain and other troublesome symptoms; affirms life and regards dying as a natural process; does not seek to either hasten or delay the onset of death; includes psychological and spiritual aspects of helping patients; offers a support system to patients so that they can live as actively as possible until death; offers a system of support to the patient's relatives during his illness, as well as during a period of bereavement; uses a multidisciplinary team approach to meet the needs of patients and their families, including during bereavement, if necessary; improves the quality of life and can also positively influence the course of the disease; applicable in the early stages of the disease in combination with other treatments aimed at prolonging life, such as chemotherapy, radiation therapy, HAART. involves conducting research to better understand and treat worrying clinical symptoms and complications.

The duty of "perjury" in relation to incurable and dying patients was a deontological (from the Greek deon - duty, logos - word, doctrine) norm of Soviet medicine. The doctor's right to "perjury" in order to ensure the right of a terminally ill person to ignorance was considered as a feature of professional medical ethics in comparison with universal morality.

The basis of this feature are quite serious arguments. One of them is the role of the psycho-emotional factor of faith in the possibility of recovery, maintaining the struggle for life, and preventing severe spiritual despair. Since it was believed that the fear of death brings death closer, weakening the body in its fight against the disease, the communication of the true diagnosis of the disease was considered tantamount to a death sentence. However, there are cases when lying did more harm than good. Objective doubts about the well-being of the outcome of the disease cause anxiety in the patient and distrust of the doctor. The attitude and reaction to the disease in patients are different, they depend on the emotional and psychological warehouse and on the value-worldview culture of the person.

Is it possible to open a diagnosis to a patient or relatives? Maybe we should keep it a secret? Or is it advisable to inform the patient of a less traumatic diagnosis? What should be the measure of truth? These questions will inevitably arise as long as healing and death exist.

At present, numerous foreign studies of the psychology of terminal patients (terminus - end, limit) are available to Russian specialists. The conclusions and recommendations of scientists, as a rule, do not coincide with the principles of Soviet deontology. Studying the psychological state of terminal patients who learned about their fatal illness, Dr. E. Kübler-Ross and her colleagues came to the creation of the concept of "death as a stage of growth." Schematically, this concept is represented by five stages through which a dying person (usually an unbeliever) passes. The first stage is the “denial stage” (“no, not me”, “this is not cancer”); the second stage is “protest” (“why me?”); the third stage is "request for a delay" ("not yet", "a little more"), the fourth stage is "depression" ("yes, I'm dying"), and the last stage is "acceptance" ("let it be") .

The stage of "acceptance" attracts attention. According to experts, the emotional and psychological state of the patient at this stage changes fundamentally. The characteristics of this stage include such typical statements of once prosperous people: “In the last three months I have lived (a) more and better than in my entire life.” Surgeon Robert Mack, a patient with inoperable lung cancer, describing his experiences - fear, confusion, despair, finally states: “I am happier than I have ever been before. These days are really the most good days of my life". One Protestant priest, describing his terminal illness, calls it "the happiest time of my life." As a result, Dr. E. Kubler-Ross writes that “I would like cancer to be the cause of her death; she does not want to lose the period of personal growth that terminal illness brings with it. This position is the result of understanding the drama of human existence: only in the face of death does a person discover the meaning of life and death.

The results of scientific medical and psychological research coincide with the Christian attitude towards a dying person. Orthodoxy does not accept perjury at the bedside of a hopelessly ill, dying person. “Hiding information about a serious condition from a patient under the pretext of preserving his spiritual comfort often deprives the dying person of the opportunity to consciously prepare for death and spiritual comfort gained through participation in the sacraments of the Church, and also darkens his relationship with relatives and doctors with distrust” .

Within the framework of the Christian worldview, death is the door to the space of eternity. Deadly illness is an extremely significant event in life, it is preparation for death and reconciliation with death, it is an opportunity to repent, pray to God for the forgiveness of sins, it is a deepening into oneself, intense spiritual and prayerful work, it is the exit of the soul into a certain new qualitative state. Therefore, it is unlikely that an Orthodox person will be surprised by the prayers to God of Elder Porfiry from the monastery in Milesi for sending him a cancerous disease and for his joy in the disease, granted to him at his request.

On this occasion, hegumen Nikon (Vorobiev, † 1963), one of the spiritual elders of our century, once wrote that cancer, from his point of view, is God's mercy to man. A person doomed to death refuses vain and sinful pleasures, his mind is occupied with one thing: he knows that death is already close, already inevitable, and he only cares about preparing for it - by reconciliation with everyone, correcting himself, and most importantly - sincere repentance before God. The disclosure of the content and meaning of the Christian understanding of the perniciousness of perjury, the meaning of illness and death becomes for many Russian doctors the basis for revising the deontological norms of Soviet medical deontology. Metropolitan Anthony of Surozh, himself a former doctor, believes that it is necessary to draw the attention of modern doctors to the fact that during the course of an illness ( we are talking about incurable diseases), a person must be prepared for death. At the same time, Vladyka Anthony says: “Prepare the dying not for death, but for eternal life.”

Arguing that the attitude of a doctor towards incurable and dying patients cannot be simply scientific, that this attitude always includes compassion, pity, respect for a person, readiness to alleviate his suffering, readiness to prolong his life, Metropolitan Anthony of Surozh draws attention to one "unscientific » approach - on the ability and "willingness to let a person die."

In 1992, the Bishops' Council of the Russian Orthodox Church canonized Grand Duchess Elizabeth Feodorovna (widow of Grand Duke Sergei Alexandrovich, son of Emperor Alexander II, killed by a terrorist in 1905). In 1909, she created the Martha and Mary Convent of Mercy in Moscow, where she was not just an abbess, but participated in all her affairs as an ordinary sister of mercy - she assisted in operations, made dressings, comforted the sick, believing: “It is immoral to comfort the dying with a false hope for recovery, it is better to help them pass in a Christian way into eternity.

Kalinowski P. Transition. // Last illness, death and after. Yekaterinburg, 1994, p. 125.

Fundamentals of the social concept of the Russian Orthodox Church. // Newsletter of the DECR of the Moscow Patriarchate. 2000. No. 8. S. 82.

Monk Agapius. The divine flame kindled in my heart by Elder Porfiry. M .: Publishing House of the Sretensky Monastery, 2000. S. 56.

Metropolitan Anthony of Surozh. Healing of the body and salvation of the soul. // Human. 1995. No. 5. S. 113.

Common truths of a general nature

Article 41 of the Law "On Health Care" guarantees the right "to receive in an accessible form information about the state of one's own health, the methods used to provide medical care, as well as the qualifications of the attending physician, other medical workers directly involved in the provision of medical care to him." And Article 46 regulates: “Information about the state of health of the patient is presented by the attending physician in a form that meets the requirements of medical ethics and deontology and is understandable to a person who does not have special knowledge in the field of healthcare.”

On the one hand, it is impossible to hide his condition from the patient, on the other hand, it is also not worth cutting the truth-womb.

Are Hippocratic advice old-fashioned for Western realities?

In the West, the dilemma "You can't say nothing" does not exist. The truth was no longer hidden from patients after high-profile litigation, when patients or their relatives demanded compensation for the fact that oncologists did not tell them about the hopelessness of the situation. The plaintiffs argued that if they knew everything as it is, they would prefer to live as long as they were measured from above, without wasting precious time and money on ineffective treatment.

Now, upon completion of the examination, all patients in the United States and European countries are given a package of documents in their hands, which sets out everything about the disease, the proposed treatment and its effectiveness. There are technical details of the intervention technique, and the risks of complications, and even predicted life expectancy.

Such a pragmatic approach is not consistent with the position of the father of all healers, Hippocrates, who taught: “Surround the patient with love and reasonable conviction, but most importantly, leave him in the dark about what lies ahead for him, and especially about what threatens him.” The ancient Greek physician above all put the ideas of humanism, mercy and service to the suffering.

Specialists working in the post-Soviet space are trying to find a golden mean in the matter of informing.

It is no coincidence that the Russian surgeon-oncologist, academician Nikolai Blokhin wrote: “There should never be patterns in the relationship between a doctor and a patient, and the obligatory telling the patient the whole truth about his illness is just as unjustified as the obligatory concealment of the truth.”

What is the position of the Belarusian doctors?

Palliative Care Specialist: Delivering bad news carefully is a science

Chief Physician Palliative care hospitals "Hospice" Olga Mychko suggests that any physician is inherently afraid of disclosing information about an incurable disease to a patient. After all, following such a message, one has to deal with strong emotions. Not every doctor is able to calmly perceive tears, anger and respond to them correctly. What if a person has a heart attack? Or will he later try to take his own life? Does he blame the doctor for what happened?

A specialist who has a huge practical experience or natural instinct, understands with whom you can be frank, and from whom you should hide the details, - says Olga Viktorovna. - And his colleague without such abilities would prefer to remain silent once again, so as not to harm the word. Competent safe presentation of medical information must be taught ...

In the USA in basic training medical workers includes a special discipline on the psychology of communication with the patient, including the section "Presenting bad news." In Belarus, only the first steps in this direction are being made so far.

In February, as part of a national seminar, the hospice organized a videoconference with representatives of the University of Massachusetts, who gave a master class to Belarusian oncologists and other doctors on this topic.

Cardiologist: With the "core" you always need to be honest and sincere

Corresponding Member of the National Academy of Sciences of Belarus Dr. med. Sciences, Honored Scientist of the Republic of Belarus Nikolai Manak I am sure that the truth about the diagnosis is necessary for all patients with cardiovascular pathology, regardless of the severity of the process. The professor himself never hides anything from those who seek help or advice. Otherwise, in his opinion, it is difficult to expect that the patient will become an assistant in treatment.

In clinical practice, you constantly encounter situations when the patient underestimates the seriousness of his situation, - says Nikolai Andreevich. - One, after he was barely “pumped out” after a heart attack, is eager to plant potatoes in the country, the other stops drinking medicines because they are expensive, and he “already felt better”, the third, after the most difficult cardiosurgery, allows himself alcohol excesses. In order to resist such frivolity, it is sometimes useful not only to frankly describe the expected scenario of the development of events, but also to exaggerate at certain moments ...

The question arises: what about the vulnerable psyche of the "core"? Isn't it scary for the doctor to strike with a joyless message?

In any case, the information must be communicated to the patient in full, - Nikolai Andreevich is convinced. - Another thing is how and when to do it.

Take such a common disease as angina pectoris. Every year, 2-4% of patients with this disease develop a heart attack and acute coronary insufficiency, from which they die. However, it is very difficult to determine whether a particular patient will fall into this small cohort. Therefore, I warn that there is a possibility of a threat to life, and if medical recommendations are not followed, the risk increases many times over.

Patients who refused explanations, Nikolai Manak in his practice can count on the fingers.

One of these was the famous statesman BSSR, who was diagnosed with extrasystole. After trying to convince the need for an in-depth examination and explain the effect of the drug, an influential patient protested: “Do not waste time. I don't need to know!" As it turned out, the reason was in full confidence in the specialist.

Oncologist: The patient must be told the whole truth when he asks for it or refuses treatment


Head of the 3rd Oncosurgical Department (Urology) of the Minsk City Clinical Oncology Center Igor Masansky states that with advanced forms of malignant tumors is less and less common. He connects this with the development of medicine, the expansion of the arsenal of means for the early detection of oncopathology and the fight against it. Twenty years ago, the specialist admits, I had to sign my impotence several times a week.

In a conversation with patients about the results of their examination, I take into account, first of all, the fact that the majority, before entering the office, are already in a state of extreme tension, says the doctor. - Unfortunately, the mystical horror of the word “cancer” has not yet been eliminated (by the way, experienced oncologists never use it when communicating with patients). It is taken as a judgment. If you directly inform a person that he has distant metastasis, the consequences will be unpredictable. Information about cancer should be quantum satis - "as much as you need."

Igor Leonidovich explains that the selection of a verbal "dosage" is no easier task than determining the volume of surgical intervention. It's one thing when you have a pensioner in front of you, whose children and grandchildren are arranged; the other is a young able-bodied man, the father of two preschoolers.

It happens that relatives ask not to tell the patient anything about the diagnosis. Thus, they try to protect the relative from additional psychotrauma.

In a conversation, especially if it is the first one, I try to soften the heavy news as much as possible: “The situation is serious, but we will do our best”, “We suspect a tumor that requires further treatment,” says Igor Masansky. - As practice shows, in half of the standard cases, patients are satisfied with such a concise message. Another 40 percent then ask one or two clarifying questions: “How long should I be treated?”, “When will it be possible to start working again?”. And only one in ten requires a detailed medical commentary and a scenario for the future life and its quality.

To the question "How much do I have left?" the doctor prefers to answer evasively:

Firstly, the boundary between favorable, doubtful and unfavorable prognosis for different nosologies, condition and age is not clear. In advanced cases, the future directly depends on the ability to apply several methods of treatment, including radical and cytoreductive (with subtotal removal of the tumor) combined operations, high-quality radiation, drug therapy using modern chemotherapy drugs. Not so rare are cases when we removed distant retroperitoneal metastases in prostate cancer (i.e., the operation was conditionally radical in nature) and the patient went into long-term remission. IN total mass there are many such lucky ones, and such facts can inspire those who find themselves in a similar situation ...

According to Igor Masansky, it is necessary to fully reveal the truth about a possible disappointing prognosis only if the patient categorically refuses the help of doctors. The message about the real threat of painful death in the absence of timely treatment can sober up and increase compliance (adherence to treatment). But if the patient has signs of mental imbalance, the truth should be hidden, and the conversation should be continued in the presence of the next of kin or guardians.

Another rule of an oncourologist in communication with the patient - even in the most hopelesscases not to deprive a person of inner

support, hope for help. And if the arsenal of surgical, radiation and medications has been exhausted, not counting

shameful to send for advice to the herbalist.

The presence of a goal, feasible physical activity, interest in life mobilize internal reserves, which allows you to extend life and improve its quality, - Igor Masansky is sure.

Chairman of the ethics commission: It is allowed to keep silent about the truth when the medical possibilities of assistance have been exhausted

A doctor with 60 years of experience, a cardiovascular surgeon, chairman of the ethical commission of the Belarusian Association of Physicians, Dr. med. sciences, professor Vladimir Krylov considers the issue of informing about the diagnosis extremely delicate and complex.

In most cases, the truth about the serious condition of the patient should be disclosed by the attending physician, - Vladimir Petrovich believes. - Not the best option if a person accidentally learns about it from medical records, from another doctor or outsiders. In such cases, trust in the specialist and medicine is easily lost.

Professor Krylov's professional interest in last years is aimed at studying such a life-threatening pathology as aneurysm. In terms of prognosis, it is worse than a tumor. It can burst suddenly - this is certain death.

If this vascular formation is confirmed, according to Vladimir Krylov, one should not be afraid of harsh formulations.

On the contrary, it is they who are able to keep patients in good shape, who should be extremely careful. For example, it is forbidden to lift weights: inadequate physical activity can provoke death. Of the 250 people observed by Krylov, two have already gone to a different world from what they decided ... to change the double-glazed windows in the apartment with their own hands.

They lifted a heavy structure - and fell.

Well, how not to give these examples when you are talking with another patient with an aneurysm! I would like him not to think of repeating such labor "exploits".

If you look at the problem from the point of view of ethics and deontology, then, of course, the words must be chosen carefully, taking into account the desire, mood and psychological features patients. Among them there are both aggressive and prone to depression, and those who do not want to listen to the doctor at all, completely shifting responsibility for their own health onto him.

One patient with life threatening pathology, he was indignant at an attempt to explain the mechanism of development of his illness: “Why do I need this! You are a doctor - you are the healer! And I had no choice but to shut up.

True, a year later this patient came again. Apparently, he thought about it and realized that they wish him well ...

Professor Krylov believes that in the case of severe nosologies, it is necessary to explain to the patient his problems, focusing on therapeutic possibilities. If, for example, the tumor is inoperable, it is not worth saying that nothing can be corrected surgically here. It is better to focus on the need to try a course of chemotherapy, radiation therapy ...

Silence is justified in a situation where there are no options for help. What will the statement of the fact of extinction give? Only despair, hastening death. Where medicine is powerless, other, unknown mechanisms of salvation are often included.

Vladimir Krylov had a patient - the head teacher of one of the Minsk schools. She was diagnosed with dysplasia connective tissue and stenosis of both renal arteries. The surgeon restored the lumen of the affected areas. Technically, everything was done flawlessly.

And soon stenosis formed again. The control angiography showed: the narrowing was formed literally in a centimeter!

The doctor realized that the operation would not help, and openly said so. In a conversation, he expressed the hope that if the patient had lived like this for more than a decade, perhaps the body would now adapt. He said goodbye, and he mentally sympathized: “So sorry, she’s still young, but she still has a year left.”

And not so long ago I accidentally met a teacher on the street! I could not believe my eyes - after all, 17 years have passed. The joyful greeting of the woman finally dispelled all doubts.

I am happy to admit that my bad forecast did not come true, and it’s good that I didn’t say about it, ”says Krylov. - We, doctors, assume a development scenario based on physical, material indicators. But, apparently, they are not always decisive.

Perhaps, only in our country the situation when doctors, relatives and even friends know the patient's diagnosis, and the patient himself remains in the dark, is the norm, not the exception.

What is more from such silence - benefit or harm - neither the attending physicians, nor psychologists, nor deontologists (specialists in ethics and morality in medicine) can unambiguously say. On one side of the scale is the right of a person to know what is happening to him, on the other - the negative consequences of such knowledge, characteristic of representatives of our culture with its fear of death.

medical approach

In many areas of medicine, patient awareness is one of the conditions for successful treatment. It is difficult to imagine a gynecologist who did not inform a pregnant woman about the threat of a miscarriage, or a hypertension discharged after a crisis without recommendations to monitor pressure.

Things are different with oncologists and other specialists who often face death. They need, on the one hand, not to finish off the patient with a terrible truth, on the other hand, to inform him about the possibilities of treatment.

In the West, the problem of silence has been radically solved - to inform the patient about everything related to his health, even in the case of hopeless diseases, if the mere fact of reporting a diagnosis does not give instant complications. Simply put, no one will immediately tell a person with a myocardial infarction a week ago about a freshly diagnosed carcinoma (one of the forms of cancer), even in America, which is concerned about the rights of the patient. But from those patients whose risk of dying this very hour is not documented, nothing will be hidden.

In domestic practice, the decision remains on the conscience of the doctor. Until now, it is not always customary to report cancer and other unfavorable prognosis, although by law any patient over 14 years of age has the right to full information about their health status and diagnoses. Often you can not get a truthful answer even in response to a direct question "Doctor, do I have cancer?". Is it legal? Yes and no.

In theory, NOT Diagnosis can only be reported if the patient himself NOT wants to know him, even if the disease NOT dangerous to those around you. But for the humanism of physicians, a loophole remains in the fundamentals of the Russian legislation on health protection: the actions of a doctor to conceal a diagnosis can be considered lawful if three conditions are simultaneously met: this is done for release the patient from moral suffering when deadly disease, which does not endanger the health of others. That is, cancer in the last stage with metastases for the benefit of the patient can be called anything, but any infectious disease is not.

However, the problem is that there is no approach that will be a boon for everyone. And here comes into force not only the medical aspect (reflection of the news on the state of health, possible refusal of therapy or, on the contrary, more conscious treatment planning, etc.) aspect, but also the moral and ethical one. Which is higher: the right of a person to know that he is dying, or the false maintenance of hope in him in an attempt to ease the last days?

death sentence

Is it possible to harm the terrible truth? Easy. If a person considers cancer a sentence, then great power self-hypnosis can hasten a sad end even at those stages when a cure is possible.

Is it possible to say that the silence of the diagnosis is an unequivocal benefit? Hardly. After all, we are not allowed to look at the situation through the eyes of the patient and understand how he wants to live the allotted time: do something important for himself, fulfill a dream, take care of loved ones, or remain in happy ignorance.

The lie "for good" has its supporters and opponents. To say "better the bitter truth than sweet lie"easier than taking hope away from loved one. Yes, we all die, but healthy human psyche the repression and denial of the irreparable is characteristic, therefore ordinary citizens who are not philosophers or deeply religious rarely think about this side of life. And it is very difficult to predict the reaction of a person who has learned that he has a few days, weeks or months left to live.

Silence as a crime

In some situations, the concealment of a diagnosis by a doctor is a crime for which there is a very real criminal liability.

Criminal acts include:

  • any attempt to cover up a medical error;
  • concealment of the diagnosis for the appointment of paid unnecessary procedures;
  • deterioration during the course of the disease, due to the patient's ignorance of the real state of affairs;
  • not informing the patient about a contagious disease.

Almost half a century ago, psychiatrist Elisabeth Kübler-Ross described five psycho-emotional states that hopelessly ill patients go through: denial, aggression, bargaining with oneself, depression, and acceptance of the inevitable. Nothing has changed since then. Some have the strength to accept the disease and live with it for the allotted time (not to be confused with depressive passivity), someone remains at the stage of denial, depression or even aggression, making the existence of loved ones unbearable.

Meanwhile, not always the person from whom the diagnosis is hidden does not know him. How do you like the story about a 76-year-old grandmother with stomach cancer, who endured terrible pain for several months so that the children would not guess that she knew everything, and it was easier for them? Everything was revealed at the stage when the old woman began to scream in pain. I will not describe the state of already elderly people who realized that their mother suffered terribly because of their silence.

Tell or not?

Arguments for

  1. When there is no need to hide anything from the patient, it is easier for specialists to plan treatment. And the patient has the opportunity to make a conscious choice of clinic and doctor.
  2. If the patient knows his diagnosis, it is easier to convince him of the need for radical treatment.
  3. Fighting a specific enemy is often more effective than fighting against who knows what.
  4. The patient has the opportunity to receive specialized psychological assistance, for example, in support groups for cancer patients.
  5. There is more trust in relationships with relatives who do not have to pretend that everything is in order.
  6. The patient has the ability to manage his life.

Arguments against

  1. Unpredictable consequences of psychological shock.
  2. The negative impact of self-hypnosis on the patient's condition.
  3. The inability to adequately assess the patient's condition (children, the elderly, patients with mental disorders).

Unfortunately, no matter what arguments for and against are given, doctors and relatives need to consider each situation with a potentially sad outcome individually, taking into account the characteristics of the character, condition, desire of a person to know or not to know the truth and prospects for treatment. But at the same time, it is better to leave the decision anyway to those whose life hangs in the balance. Find out if the person wants to know the terrible truth or not (it can be done in a roundabout way). And if he wants, he must know her. And what to do with this truth is the personal choice of the patient. Will he go for a hopeless operation, refuse to be treated, commit suicide, open a cat shelter with the last money, want to make peace with his enemies, or pretend that nothing happened.

To speak or not to hush up the diagnosis is a problem, in the solution of which it is necessary to proceed from the aspirations of the patient himself, and not from the convenience of those around him. The task of relatives in such a situation is to help and support, and a person is free to end his days as he sees fit.

Olesya Sosnitskaya